Provider Demographics
NPI:1710767975
Name:JOHNSON, SERENA MALIA
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:MALIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ELLEN POLIMENI BLVD APT 508
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-2254
Mailing Address - Country:US
Mailing Address - Phone:631-626-9642
Mailing Address - Fax:
Practice Address - Street 1:1057 E HENRIETTA RD STE 500
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2655
Practice Address - Country:US
Practice Address - Phone:585-258-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028433225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist